Well Done For Taking Your First Steps!

Your healing journey is unique to you and I’d love to say it’s simple as making diet changes, or better yet, to take a magic pill. Fortunately the magic pill is to have an open mind and a willingness to improve. Always remember that the fun and adventure is in the journey, so enjoy every moment and everyday because it will allow you will reach your destination a lot sooner than you may think.

This form should take 2-3 minutes to complete and all fields are mandatory.

A Little Bit About You

Full Name

Country

What is your date of birth?

What is your height and weight?

Your Condition

Do you currently suffer from an Autoimmune disease, IBD, IBS or any other gut issues? If so, please specify.

What year was you diagnosed with the condition?

List all of your current symptoms. Even ones that you feel aren't linked to your gut.

What medication or treatment are you currently on?

Have you had surgery before due to your condition? If yes, please specify.

Are you due to have surgery or has it been discussed with your doctor, for the near future? If so, what surgery and when?

How many times a day do you open your bowels?

How often do you have a flare up? E.g. everyday, once a week, once a year etc.

On average, how long does a flare up last?

Do you have any of the following. You can select multiple options.

What allergies or intolerances do you have?

Do you currently take any non-prescribed supplements or tablets? If so, please specify.

Have you had a blood test in the last 3 months? If so, did it raise any deficiencies or underactive organs?

Are you deficient in any vitamins or minerals? If yes, then please list them.

Your Current Diet

Which of these best describes to your eating habits?

How many times a day do you eat and typically at what times do you eat?

List the foods or meals you would typically eat - this doesn't have to be a long list.

Do you snack? If yes, how often and what do you generally snack on?

Do eat any sweet or sugary food? If yes, how many much per day?

What do you drink each day?

Do you drink caffeine? If so, how many cups per day?

Lifestyle Habits

Does your work involve mild, moderate or intense activity? E.g. sitting at a desk is mild

Are you physically active or workout? E.g. mild activity is walking. Intense activity is weight training.

How many days a week are you physically active?

Do you consume alcohol? If yes, how many units per week? E.g. a single shot of spirits is 1 unit, 1 can of beer/lager/cider is 2 units, large glass of wine is 3 units

Do you smoke tobacco or vape? If yes, how many times a day?

Do you take recreational drugs? E.g. marijuana.
YesNoSometimesRather not say

What time do you usually go to sleep and wake up? If your timings are different on weekends or non-work days, then please specify.

On a scale of 1-10, how stressed are you? 1=not stressed and 10=extremely stressed.
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On a scale of 1-10, what is your readiness to improve and transform your life? 1=not ready and 10=let's do this!
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